USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1962 > Part 15
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163 Sewall Avenue
Winthrop, Mass.
St
(If nonresident, give city or town and State)
2 ... months. LLdays. In place of residence.
1 __ years .... -. months ..... .. days.
MEDICAL CERTIFICATE OF DEATH
14,
1962
(Day)
(Year)
REBY CERTIFY,
That I
4/14
I last saw
ima
4/12
19.6.2 death is said to
have occurred on the date stated above, at 9:00A.
m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Cerebral Hemorrhage
Due To Gen '1 Arteriosclerosis (b)
OTHER
Hypostatic broncho
1d
5 Was disease or injury in any way related to occupation of deceased ? If so, specify
M. D.
(Address)
Somerville Mass Date.
4-16
1962
Medford, Mass.
(City or Town)
,62
19
7 NAME OF
FUNERAL DIRECTOREdmund L .Kelleher
ADDRESS
67 Broadway , Somerville
Received and filed
MAY 2-1962
19
(Registrar of City or Town where deceased resided)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
white
10 SINGLE
(write the word)
MARRIED WIDOWED DIVORCED Widowed UNKNOWN
11 If married, widowed, or divorced
HUSBAND of
Bridget Anne Lynch
(Give maiden name of wife in full)
INTERVAL
BETWEEN
ONSET AND
(or) WIFE of ..
DEATH
12
3 days AGE 84 Years
... Months ......
.Days
(Husband's name in full)
If under 24 hours
Hours ........ Minutes
13 Usual
Occupation:
Storekeeper-Retired
(Kind of work done during most working life)
14 Industry
or Business :
Storekeeper own business
15 Social Security No.
16 BIRTHPLACE (City)
(State or country)
Ireland
17 NAME OF
FATHER
C.N.B.L.
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Ireland
19 MAIDEN NAME
OF MOTHER
C.N.B.L.
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Ireland
S, Xavier
21 Informant
(Address)
186 Highland Ave. Somerville
A TRUE COPY
ATTEST:
(Registrar of City or Town where death occurred)
DATE FILED
Apr. 17
196.2.
/ X'
2 FULL NAME.
(a)
Residence. No.
(Usual place of abode)
Length of stay: In place of death .......... years.
3 DATE OF
DEATH
April
(Month)
4
6/2/61
19
(a)
Due To
(c)
SIGNIFICANT
Was autopsy performed ?
What test confirmed diagnosis ?
(Signed) Thomas A Kelley
52 Central Street
Oak Grove Cem.
6
Place of Burial or Cremation
DATE OF BURIAL
Apr. 17
at the time of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased
Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town
resided as soon as possible, after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.)
CONDITIONS
pneumonia
50M - 10-61-931673
PLACE OF DEATH
ORM R-302
WRITE PLAINLY, WITH UNFADING BLACK INK OR USE APPROVED BLACK TYPEWRITER RIBBON - THIS IS A PERMANENT RECORD
m.c.
Middlesex (County) Somerville
(City or Town) Little Sisters of the Poor No ..
186 ... HighlandAvenue
(Was deceased a
U. S. War Veteran,
if so specify WAR,
Male
attended deceased from
19.62
3 yrs
PARENTS
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT SERVICE NUMBER
TOWI
1
D
0
THROP
MAY - 21962 AM
ORM R-301
1
Winthrop (City or Town)
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH
Registered No.
26 .....
S (If death occurred in a hospital or institution, .St. ¿ give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
2 FULL NAME. Myer Kumins
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No ... 329 A Shirley St. Winthrop Mass
(Usual place of abode)
Length of stay: In place of death .......... years .......... months ....
7 days. In place of residence ......... years ...
... months ...
... days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
April
17
19620
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY
Jan,
56
to ......
April 17.
I last saw hingalive on
April 17, 1962 death is said to
have occurred on the date stated above, at 8:00Pm.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Lympho sarcoma.
Due To (b)
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
None
Was autopsy performed?
What test confirmed diagnosis? Clinical, Pathological
5 Was disease or injury in any way related to occupation of deceased ? If so, specify
(Signature)
Cheartes Liberman
L, M. D.
CHARLES
LIBERMAN
(Address)
Winthrop, Mass Date 4/17/1962
Tifereth Israel of WinthropEverett 6
Place of Purial or Cremation
(City or Town)
DATE OF BURIAL
April 18,
,62
7 NAME OF
FUNERAL DIRECTOR
Benjamin Birnbach
ADDRESS 1668 Beacon St Brookline
Received and filed 19
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10 SINGLE
(write the word)
MARRIED
WIDOWED
DIVORCED
UNKNOWNSingle
11 If married, widowed, or divorced HUSBAND of (Give maiden name of wife in full)
(or) WIFE of.
(Husband's name in full)
12
AGE
Fears
50,
Months ...
Days
If under 24 hours
Hours ... ... Minutes
13 Usual
Occupation :
Painter
14 Industry
or Business :
Smithcraft Fixture Co
15 Social Security No 030-07-6334
16 BIRTHPLACE (City).
(State or country)
Boston Mags
17 NAME OF
FATHER
Simon Kuming
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Russia
19 MAIDEN NAME
OF MOTHER
Fanny Sherman
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Russia
21 Informant
(Address)
31 Hawthorne Ave Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued:
(Signature of Agent of Board of Health or other) Hledlate Notice
4/18/18
(Registrar) || (Official Designation) ONLIST.1 T. I be HEMO15
(Date of Issue of Permit)
K VI -
ʼ
A TRUE COPY ATTEST:
PLACE OF DEATH
for burial permit bard of Health its Agent. TRUCTIONS FOR CL CERTIFICATE
1
LI
If OR TYPE OR CAUSES DEATH
not enter le than one de for each (b) and (c)
does not mean de of dying, heart failure, etc. It means ase, or compli- which caused
ions, if any, gave rise to cause (a), the under- cause last.
ditions contrib- death but not to the terminal econdition given
PR 18 1962 62-932382
X Suffolk (County)
No.Winthrop Community Hospita .....................
(City or Town making this return)
(Was deceased a U. S. War Veteran, if so specify WAR) No
(If nonresident, give city or town and State)
That I attended deceased from
INTERVAL BETWEEN ONSET AND DEATH 8 wlgs.
(Kind of work done during most working life)
PARENTS
Albert Kuming
(Print or Type Name)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
1
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
0
RULES OF PRACTICE APR 1 81962 FM
The fulfillment of the purpose of these laws calls for the observance of the following rules of practice: (1) Attending physicians will certify to such deaths only as those of persons to whom they have given bedside care during a last illness from disease un- related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably due to injury. These include not only deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons), thermal, or electrical agents, and deaths following abortion, but also deaths froin disease resulting from injury or infection related to occu- pation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
Statement of Cause of Death .- Physicians: see explanatory instructions on face side of standard certificate of death.
Statement of Occupation .- Precise statement of occupation is very impor- tant, so that the relative healthfulness of various pursuits can be known. Make some entry in this section for every person aged 10 years or over. If the occupa - tion had been given up or changed, or if the deceased had retired from business, report the kind of work done during most of working life even if retired. Chil- dren not gainfully employed may be returned as at school or at home. For a woman whose only occupation was that of home housework, write housework. For a person engaged in domestic service for wages, however, designate the occupation by the appropriate terms, as housekeeper-private family, cook -- hotel, etc. For a person who had no occupation whatever write none.
X
PLACE OF DEATH
Suffolk (County)
Winthrop (City or Town)
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH Registered No.
To be filed for burial permit with Board of Health or its Agent.
§(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
(Was deceased a
U. S. War Veteran,
no
[if so specify WAR)
(a) Residence. No.
47 Sunnyside Ave.
St.
Winthrop
(Usual place of abode)
(If nonresident, give city or town and State)
Length of stay: In place of death.
3
.years.
........ months .............. days. In place of residence.
3 ..
.years.
.months.
.... days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
April
19,
1962
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
19
to
19
I last saw h ........ alive on
19
death is said to
have occurred on the date stated above, at
3 0m
INTERVAL BETWEEN ONSET ANO DEATH
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
Death due to natural causes,
(a)
presumably acute coronary
Due
(b)
occlusion, due to known
arteriosclerotic and
Coronary artery heart
Due To
disease
Winthrop Boardof Health
SIGNIFICANT
CONDITIONS
OTHER
Charles Libe mu
Was autopsy performed?
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased ? no If so, specify ....
(Signed)
Charles
CHARLES
LIBERMAN
(PRINT OR TYPE SIGNATURE)
(Address) WINTHROP Date .. 4/19/162
Holy Cross Cemetery, Malden
Place of Burial or Cremation
DATE OF BURIAL
April
2.3,
7 NAME OF
Ernest P. Caggiano
FUNERAL DIRECTOR
ADDRESS 147 Winthrop St., Winthrop
Received and filed APR 23 1962 .19.
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
male
9 COLOR
white
10 SINGLE
(write the word)
married
MARRIED
WIDOWED
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of
Catherine .D ....... Smith
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
70
4
Days
If under 24 hours
Hours ..
Minutes
13 Usual
Retired Fire Lieutenant
Occupation :
(Kind of work done during most of working life)
14 Industry
or Business :
Boston Fire Dept.
15 Social Security No.
16 BIRTHPLACE (City)
(State or country)
Bo.s.ton
17 NAME OF
FATHER
Patrick J. Canavan
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Ireland
19 MAIDEN NAME
1. 1).
OF MOTHER
Emma L. Dubberley
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Nova Scotia
21
Mrs. Catherine D. Canavan
Informant
(Address)
47 Sunnyside Ave. , Winthrop
I HEREBY, CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: 19 albli @ tireauns 4
{Signature of Agent of Board of Health or other)
4/23/68
(Official Designation)
(Date of Issue of Permit)
TRUCTIONS FOR AL CERTIFICATE
1 giving : OF DEATH not enter e than one a.e for each . (b) and (c)
edoes not mean de of dying, heart failure, etc. It means ase, or compli- which caused
ions, if any, gave rise to cause (a), the under- cause last.
e ditions contrib- death but not to the terminal condition given
t Chapter 137, 1954. requires Phins to print or le čause or of death on rtificates, and 48. Acts of quires Physi- print or type der signature.
0.11-59-926662
IM R-301A 1
No.
47 Sunnyside Ave.
JOSEPH I. CANAVAN
2 FULL NAME.
(If deceased is a married, widowed or divorced woman, give also maiden name.)
PARENTS
(City or Town) 19.6.2
6
AGE
Years
Months
12
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER.
RULES OF PRACTICE APR .231962 AM
The fulfillment of the purpose of these laws calls for the observan following rules of practice: (1) Attending physicians will certify to such deaths only as those of persons to whom they have given bedside care during a last illness from disease un. related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably due to injury. These include not only deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons) thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting from injury or infection related to occu. pation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
Statement of Cause of Death .- Physicians: see explanatory instructions on face side of standard certificate of death.
Statement of Occupation .- Precise statement of occupation is very impor- tant, so that the relative healthfulness of various pursuits can be known. Make some entry in this section for every person aged 10 years or over. If the occupa - tion had been given up or changed, or if the deceased had retired from business, report the kind of work done during most of working life even if retired. Chil- dren not gainfully employed may be returned as at school or at home. For a woman whose only occupation was that of home housework, write housework. For a person engaged in domestic service for wages, however, designate the occupation by the appropriate terms, as housekeeper-private family, cook- hotel, etc. For a person who had no occupation whatever write none.
X PLACE OF DEATH
Suffolk (County)
Winthrop
(City or Town)
No.
5 Irwin St.
The Commonwealth of Massachusetts JOSEPH D WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH Registered No.
To be filed for burial permit with Board of Health or its Agent.
78
S(If death occurred in a hospital or institution, St. Į give its NAME instead of street and number)
2 FULL NAME
Walter T. Glassett
(If deceased is a married, widowed or divorced woman, give also maiden name.)
5 Irwin
St.
Winthrop
(Ii nonresident, give city or town and State)
Length of stay: In place of death.
2
years
months
.days. In place of residence ..
2
.. years.
.. months
days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
male
9 COLOR
white
10 SINGLE
MARRIED
(write the word)
WIDOWED widowed
or DIVORCED
4 I HEREBY CERTIFY, That I attended deceased from
19 .....
.. , to ..
19-
I last saw h. -.. alive on
~19 ........ , death is said to
have occurred on the date stated above, at
2:10 p.m.
INTERVAL
BETWEEN
ONSET AND
DEATH
-
12
AGE
69
Years
Months.
.Days
If under 24 hours
Hours.
Minutes
Je To Presumably Coronary
Odclusion
sudden
13 Usual
Occupation :
Supervisor
(Kind of work done during most of working life)
14 Industry
or Business :
Submarine .... Signal
Du
(c)
...
Arteriosclerotic Heart Disease years
15 Social Security No.
16 BIRTHPLACE (City)
(State or country)
Mass
Everett
17 NAME OF
FATHER
Thomas Glassett
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Mass
19 MAIDEN NAME
(Signed)
Arthur C. Murray
M. D.
OF MOTHER
Elizabeth Whalen
20 BIRTHPLACE OF
East Boston
Mass
6
Holy Cross Cemetery, Malden
(City or Town)
19.
Place of Burial or Cremation
DATE OF BURIAL
April 24,
62
7 NAME OF
FUNERAL DIRECTORErnest P .Caggiano
ADDRESS 147 Winthrop St., Winthrop
Received and filed
APR 25 1962
19
(Registrar)
PARENTS
21
Informant
Walter T. Glassett Jr.
(Address)
59 Beal St., Winthrop
I HEREBY, CERTIFY that a, satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued:
(Signature of Agefit of Board of Health of other) Health Ofhier
4/27/68
(Official Designation)
(Date of Issue of Permit)
X
R-301A 1
JUCTIONS DR CERTIFICATE
giving OF DEATH ot enter :han one for each b) and (c)
es not mean of dying, seart failure, tc. It means ·, or compli- hich caused
ns, if any, ave rise to rause (a), tthe under. ause last.
v'ions contrib- T'eath but not I the terminal Indition given
Chapter 137, 154. requires s to print or cause or f death on rificates, and r48, Acts of quires Physi- print or type ler signature.
1-59-92 5686
1
(b)
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Natural
Causes
10a If married, widowed, or, divorced
HUSBAND of
Catherine Foley
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
OTHER
SIGNIFICANT
CONDITIONS
none
Was autopsy performed?
no
What test confirmed diagnosis ? post mortem judgement
5 Was disease or injury in any way related to occupation of deceased ? no
If so, specify
Arthur C. Murray
SPRINT OR TOPE SIGNATURE Health
Winthrop Board Peter's April
62
MOTHER (City)
(State or country)
East Boston
(Give maiden name of wife in full)
3 DATE OF
DEATH
April 20, 1962
(Month)
(Day)
(Year)
PHYSICIAN - IMPORTANT [(Was deceased a U. S. War Veteran, lif so specify WAR) no
(a) Residence. No.
( {'sual place of abode)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
: :
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE APR 2 51962 AM
The fulfillment of the purpose of these laws calls for the observance of the following les of practice : (1) Attending physicians will certify to such deaths only as those of persons to whom they have given bedside care during a last illness from disease un. related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably due to injury. These include not only deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons) thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting from injury or infection related to occu- pation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
Statement of Cause of Death .- Physicians: see explanatory instructions on face side of standard certificate of death.
Statement of Occupation .- Precise statement of occupation is very impor- tant, so that the relative healthfulness of various pursuits can be known. Make some entry in this section for every person aged 10 years or over. If the occupa - tion had been given up or changed, or if the deceased had retired from business, report the kind of work done during most of working life even if retired. Chil- dren not gainfully employed may be returned as at school or at home. For a woman whose only occupation was that of home housework, write housework. For a person engaged in domestic service for wages, however, designate the occupation by the appropriate terms, as housekeeper-private family, cook- hotel, etc. For a person who had no occupation whatever write none.
X
)RM R-302
WRITE PLAINLY, WITH UNFADING BLACK INK OR USE APPROVED BLACK TYPEWRITER RIBBON - THIS IS A PERMANENT RECORD
Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town
resided as soon as possible, after the close of the month in which the death occurred. (See Chap. 46, Sec. 12. G. L.)
1
PLACE OF DEATH
Suffolk (County)
Revere
(City or Town)
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF
CERTIFICATE OF DEATH
Registered No.
S (If death occurred in a hospital or institution,
Xt. [ give its NAME instead of street and number)
2 FULL NAME
Israel Rantz
(If deceased is a married, widowed or divorced woman, give also maiden name.)
19 Underhill
Winthrop, Mass.
St
(a) Residence. No .. ( Usual place of abode )
(If nonresident, give city or town and State)
Length of stay: In place of death.
....... years .......... months .......... days. In place of residence ..
13 ears ......
... months .......... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
April
23,
1962
(Month)
(Day)
(Year)
8 SEX
Male
9 COLOR
White
MARRIED
WIDOWEMarried
or DIVORCED
4 I HEREBY CERTIFY. Aug. 23
19.
61
to .....
Apr1123
19.6.2
I last saw h .. 1Mive on
April .... 2.3
1962., death is said to
6:30A.
I.m.
INTERVAL BETWEEN ONSET AND DEATH
11 IF STILLBORN, enter that fact here.
82
12
AGE
Years.
Months .......... Days
If under 24 hours
Hours ...
.Minutes
13 Usual
Occupation :
Retired
(Kind of work done during most of working life)
14 Industry
or Business :
Tailor
15 Social Security No.
16 BIRTHPLACE (City)
(State or country)
Russia
17 NAME OF FATHER Kpel Rantz
18 BIRTHPLACE OF
FATHER (City)
(State or country )
Russia
learned) -
Morris I. Sacks
(Signed )
45 Shirley Ave.
(Address ) Revere
Date.
Apr.23,. 62
Workmens Circle
Melrose, Mass
6
Place of Burial or Cremation
(City or Town) April 24,
62
19
20 BIRTHPLACE OF
MOTHER (City)
Russia
(State or country)
Lester Henry
Informant 7.3 ...... Beat St ..........
( Address )
Winthrop, Mass.
A TRUE COPY
ATTEST :
meLise Schicht
(Registrar of City or Town where death occurred )
DATE FILED
April 24,
19 62
( Registrar of City or Town where deceased resided )
10a If married, v
HUSBAND of
Be's yfred Freeman
(Give maiden name of wife in full)
(or) WIFE of.
( Husband's name in full)
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
(a) Coronary Thrombosis
Du (b)
Arteriosclerotic Ht. Dz.
10yr.
Due TGeneralized Arteriosclerosis (c)
20yrs.
OTHER SIGNIFICANT CONDITIONS
Was autopsy performed? No
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased ? If so, specify
No
PARENTS
19 MAIDEN NAME
OF MOTHER
Gussie (Cannot be/
M. D.
50M-9-59-926111
7 NAME OF FUNERAL DIRECTOR 470 Harvard St., Brookline
ADDRESS
Received and filed MAY 10 1962 19
21
DATE OF BURIAL
Morris Brezniak
-
at the time of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased
Revere
(City or Town making this return)
No.
Annemark .... Nursing Home
( Was deceased a
U. S. War Veteran.
No
if so specify WAR,
That I attended deceased from
have occurred on the date stated above, at
10 SINGLE
(write the word)
- v. By
TO:
1
HROR
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT SERVICE NUMBER
MAY 1 01962 AM
PLACE OF DEATH
Suffolk:
(County)
in pro,
(City or Town)
La., . Convalescent Ion
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
To be filed for burial permit with Board of Health or its Agent.
80
(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number) PHYSICIAN - IMPORTANT [ ( Was deceased a { U. S. War Veteran,
2 FULL NAME
Goor-e Fratch
(First Name)
(Middle Name)
(Last Name)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
104 Highland 've.
St.
3
(If nonresident, give city or town and State)
Length of stay: In place of death.
years.
.months.
.days. In place of residence
years.
months.
days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
1. 010
9 COLOR
Chite
MARRIED
WIDOWED
or DIVORCED
Hidoved
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
June
099, to april
2,
That I attended deceased from
,62
I last saw h.L/malive on
2 c/, 1962
death is said to
have occurred on the date stated above, at
8:10Am.
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
33
2
1
If under 24 hours
AGE
Years.
Months.
Days
Hours ...........
.Minutes
13 Usual
Occupation :
Toute bale : an
(Kind of work done during most of working life)
14 Industry
or Business :
' ilk
15 Social Security No.
CA3-09-1377
16 BIRTHPLACE (City)
(State or country)
17 NAME OF
FATHER
Acorge Fatch
18 BIRTHPLACE OF
Unable to obtain
FATHER (City)
(State or country)
19 MAIDEN NAME
OF MOTHER
Josephine Tewksbury
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Unable to obtain
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
April 27
62
19
7 NAME OF
FUNERAL , DIRECTOR
Howard S Reynolds
winthrop Lass
ADDRESS
Received and filed APR 26 1962 19.
(Registrar)
PARENTS
21
Informant
Lecords Old
ase Bureau
(Address) Town of intirop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Talkh & Sureanugy f (Signature of Agent of Board of Health or other) Health Check 4/26/62
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